An update on the medical treatment of ectopic pregnancy

Diagnosis and Management of an Intramyometrial Ectopic Pregnancy Within a Septate Uterus

BACKGROUND

An intramyometrial pregnancy is a rare form of ectopic pregnancy, making up an estimated 1% of all ectopic pregnancies. Previously described management options have included surgical excision in the emergency setting.

CASE

A 32-year-old woman, gravida 4 para 0, at 6 0/7 weeks of gestation by last menstrual period, was noted to have a gestational sac implanted entirely within the uterine myometrium. Ultrasonography and magnetic resonance imaging confirmed the presence of an intramyometrial ectopic pregnancy within a septate uterus. The patient's abnormal pregnancy was successfully treated with multidose methotrexate.

CONCLUSION

Intramyometrial pregnancy is a rare entity that should be considered when it is suggested by ultrasonography or if an intrauterine pregnancy is surgically inaccessible from the endometrial cavity. In a stable patient, multidose systemic methotrexate may be a feasible management strategy.

Laparoscopy-assisted suprapubic salpingectomy 'Kaya technic' - a low-cost treatment of ectopic pregnancy

We aimed to demonstrate the feasibility and total cost of laparoscopy-assisted suprapubic salpingectomy (LASS), which utilises conventional open surgery equipment without any sealing or coagulation devices and reduces port sites compared to conventional laparoscopy (CL). Fifty-seven consecutive, age-matched patients presenting with a tubal pregnancy were enrolled. In the LASS group, a 10 mm reusable umbilical optical trocar and a 10 mm suprapubic trocar was used. The other 30 patients were managed with multiport CL. All of the patients were asked to use the visual analogue scale and Patient and Observer Scar Assessment Scale to evaluate their cosmetic satisfaction. The duration of surgery was 21.19 ± 2.33 minutes for the LASS group and 36.9 ± 4.9 minutes for the CL group (p < .001). The postoperative 6th-hour VAS score was 2.44 ± 0.5 for the LASS group and 3.03 ± 0.8 for the CL group (p: .005). All of the PSAS and OSAS parameter scores were significantly lower in LASS group than CL group. In conclusion, the LASS procedure is a feasible method for treating ectopic pregnancies with a shorter surgical duration, lower VAS scores, and better cosmetic scores than CL. Impact statement What is already known on this subject? Laparoscopy or laparotomy may be performed for the surgical management of ectopic pregnancy. Conventional laparoscopy has some advantages such as shorter hospital stay and recovery time and the better cosmetic results. However, the equipment used in conventional laparoscopy and single incision laparoscopy are more expensive than conventional open surgery equipment. What the results of this study add? Laparoscopy-assisted suprapubic salpingectomy (LASS) method has shorter operation time, lower VAS scores, better cosmetic scores and cheaper than conventional laparoscopy. What the implications are of these findings for clinical practice and/or further research? The LASS procedure looks like a feasible method for treating ectopic pregnancies and the feasibility of this procedure should be confirmed by a larger series of patients and randomised trials.

Single-dose methotrexate for the treatment of ectopic pregnancy: Our experience from 2010 to 2015

Objective:

To evaluate the success of systemic single-dose methotrexate (MTX) treatment in patients with ectopic pregnancy (EP) and to investigate factors related to treatment success.

Methods:

This retrospective study had been performed in Yildirim Beyazit University between January 2010 and December 2015. Demographic and clinical characteristics, ultrasonografic findings, pretreatment serum β–human chorionic gonadotropin (β-hCG) and progesterone levels of 58 patients with EP were retrieved from hospital records retrospectively. The patients were grouped according to MTX treatment success (response vs. failure).

Results:

Single-dose MTX-treatment was successful in 72.4% (42/58) of patients. The mean pretreatment β-hCG level was significantly lower in responders than in failures (2080 ± 2322 vs. 5707 ± 3885 IU/L, p = 0.001), and 2678 IU/L was the most suitable cutoff to predict success (75% sensitivity, 73.8% specificity). Moreover, failure rate was 8.45 times more in group of patients whose β-hCG values were determined above the cutoff. The presence of fetal cardiac activity adversely affected treatment success (odds ratio = 12, p = 0.004). Treatment success was not affected by past history of ectopic pregnancy, thickness of endometrium, progesterone value or presences of pseudosac and free pelvic fluid.

Conclusion:

The success rate of single dose MTX in this study was 72.8 %, and we found that failure rate of MTX treatment was 8.45 times more in group of patients whose initial serum β-hCG values were above 2678 IU/L and 12 times more in patients with fetal cardiac activity

Routine Monitoring of Liver, Renal, and Hematologic Tests After Single- or Double-Dose Methotrexate Treatment for Ectopic Pregnancies After In Vitro Fertilization

STUDY OBJECTIVE

To investigate the trends in liver function tests (LFTs), renal function tests (RFTs), and complete blood count (CBC) between day 1 and day 7 after single- or double-dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies.

DESIGN

Single center, retrospective chart review (Canadian Task Force classification II-3).

SETTING

University-affiliated center.

PATIENTS

All patients with a sonographically confirmed ectopic pregnancy after fresh in vitro fertilization-embryo transfer cycles between January 2004 and June 2013 treated with MTX were included.

INTERVENTIONS

Single- or double-dose MTX treatment.

MEASUREMENTS AND MAIN RESULTS

LFTs, specifically alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, and total bilirubin levels, were measured on day of MTX administration (baseline) and 7 days later (day 7). Similar measurements of RFTs (blood urea nitrogen [BUN] and creatinine) and CBC (white blood cell [WBC] and platelets) were also performed. The change in LFTs, RFTs, and CBC (Δ) between baseline and day 7 was calculated for both single- and double-dose MTX protocols. Furthermore, the change in LFTs, RFTs, and CBC (Δ baseline vs day 7) for single- and double-dose MTX protocols were compared. Complete data was available for 107 patients: 89 (83.2%) and 18 (16.8%) patients received single- and double-dose MTX treatment, respectively. For either single- or double-dose treatment, no significant difference was found between baseline and day 7 ALT, AST, albumin, total bilirubin, BUN, creatinine, WBC, or platelet levels after MTX treatment. A comparison of post-treatment changes in LFTs, RFTs, and CBC (Δ baseline vs day 7) also showed no difference between single- and double-dose protocols.

CONCLUSION

Our study suggests that repeating LFTs, RFTs, or CBC on day 7 after single- or double-dose MTX treatment for sonographically confirmed ectopic pregnancies may not be necessary in patients with normal baseline testing on day 1.

Predictors of Success of a Single-Dose Methotrexate in the Treatment of Ectopic Pregnancy

BACKGROUND

Ectopic pregnancy (EP) is the commonest cause of maternal mortality-related death in the first trimester. Methotrexate (MTX) remains the first-line treatment in optimally selected patients.

OBJECTIVE

To evaluate the success rate and predictors of success of a single-dose MTX treatment in EP.

SUBJECTS AND METHOD

We studied retrospectively 109 patients with unruptured EP who were treated with Intramuscular MTX administered in a dose of 50 mg/m(2) on days 0 and in additional doses on day 7 if β-hCG levels did not decrease by 15 % during the follow-up period. The study was conducted at the Maternity and Children Hospital Buraidah, Saudi Arabia from June 2013 to December 2013. Pretreatment β-β-hCG, EP mass diameter, peritoneal fluid, and fetal cardiac activity were evaluated. The main outcome measures were success rate, the predictors of success without surgical treatment.

RESULT

Under this regime, the overall success rate was 60.6 % of patients. Of the failure group, only 4.7 % of patients experienced rupture of EP. No side effects were reported. The main predictors of failure were initial β-hCG value ≥ 3.500 mIU/mL OR 4.11 (1.646-12.248, 0.043) and EP diameter 3.73 (1.646-12.10, p = 0.003).

CONCLUSION

The success rate of MTX in this study was 60.6 %, and the initial β-hCG concentration and EP diameter were the best predictors of successful treatment with MTX. Furthermore, MTX should be offered only to those patients with β-hCG <2,000 mIU/mL and EP mass size <3.5 cm.

The Use of Intravenous Methotrexate in the Treatment of Ectopic Pregnancy

Between January 1996 and December 2001, at the Department of Gynecology, Perinatology and Human Reproduction of the University of Florence, 49 ectopic pregnancies were submitted to medical treatment. The treatment schedule consisted of the administration of 100 mg of intravenous methotrexate (MTX). The patients included in this study fulfilled the following requisites: gestational period <8 weeks; diameter of the ectopic gestational sac <4 cm; serum level of human chorionic beta-gonadotropin (beta-hCG) <5000 IU/ml; absence of clinical and ultrasound signs of tube rupture with initial hemoperitoneum; hematochemical tests compatible with chemotherapic treatment. All patients were followed with a dosage of serum beta-hCG repeated every 2-3 days after chemotherapy and with an ultrasound every 3-4 days. In case of documented success of treatment the patient was hospitalized for no more than 3 days after administration of the drug. In 1 case therapy took place in a day-hospital regimen. Medical treatment was effective in 35 patients out of 49 (71.4%) and led to negative beta-hCG in a median time of 11 days, with a range between 2 and 48 days. In the 14 non-responsive cases (28.6%), after a mean time of 6 days we proceeded to a traditional surgical approach or laparoscopy. In none of the cases did we find significant pharmacological toxicity, while in 9 patients (18.3%), severe painful symptoms appeared immediately after treatment, but resolved within 24 hours. Our results are interesting and in agreement with other experiences found in the literature. In our opinion, the advisability of a second administration in case of slow response, the comparison with an analogous intramuscular treatment, a more precise definition of the eligibility criteria, long-term follow-up of the patients, especially in case of subsequent pregnancies should all be further considered.

Systemic methotrexate: An effective alternative to surgery for management of unruptured ectopic pregnancy

BACKGROUND

Medical management of an unruptured ectopic pregnancy with intramuscular methotrexate is a common and cost-effective alternative to surgery. Early diagnosis and timely institution of methotrexate has resulted in a dramatic decline in the morbidity, mortality and financial burden associated with ectopic pregnancy. The objective of our study was to evaluate the efficacy of medical management in a series of patients with unruptured ectopic pregnancy meeting the strict inclusion criteria.

METHODS

Multiple dose methotrexate regimen was utilized for the management of the cases. Parenteral methotrexate 1 mg/kg was administered on Day 1, Day 3, Day 5 and Day 7 whereas rescue dose of injection leucovorin 0.1 mg/kg was given on Day 2, Day 4, Day 6 and Day 8. Monitoring for the resolution of the ectopic was carried out with β-hCG, done on Day 1, Day 3, Day 5, and Day 7. Any value showing a decline of >15% of the baseline value led to the termination of treatment and only surveillance was carried out. If the decrease was <15%, treatment was continued.

RESULTS

Total 43 patients with ectopic pregnancy were diagnosed over a period of 1 year, conceived during infertility evaluation and treatment. 11 cases went directly for surgery whereas 32 were subjected to medical treatment. 75% of the patients got successfully treated and rest 25% required surgery following failed medical management.

CONCLUSIONS

Methotrexate therapy is a safe and effective alternative for the management of unruptured ectopic pregnancies with minimal or no side-effects and associated advantage of avoiding invasive surgery.

Role of routine monitoring of liver and renal function during treatment of ectopic pregnancies with single-dose methotrexate protocol

OBJECTIVE

To assess whether or not baseline serum transaminases and creatinine measurements, before administration of methotrexate, identified significant liver or kidney disease, which have the potential to alter the management plan for the treatment of ectopic pregnancies.

DESIGN

This is a retrospective study of patients treated for ectopic pregnancy.

SETTING

Women's emergency room and reproductive endocrinology office at a teaching hospital over a 3-year period.

PATIENT(S)

Women presenting for treatment of ectopic pregnancy.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Assessment of baseline serum transaminases and creatinine measurements before administration of methotrexate to identify significant liver or kidney disease.

RESULT(S)

A total of 383 patients were managed for ectopic pregnancy from January 2006 to December 2008. Of these, 320 patients received methotrexate as part of their treatment. No patient was denied treatment with methotrexate secondary to concerns regarding liver or renal function. No complication related to methotrexate administration was documented. A subgroup of 81 patients had pre- and postadministration labs, and no significant difference was noted upon comparing the values.

CONCLUSION(S)

Routine measurement of serum aspartate aminotransferase and creatinine levels may not be necessary before instituting a single-dose methotrexate treatment regimen for the management of ectopic pregnancy.

Laparotomy to laparoscopy: changing trends in the surgical management of ectopic pregnancy in a tertiary care teaching hospital

STUDY OBJECTIVE

To review the changing trends in the surgical management of ectopic pregnancy and to evaluate the effect of an ongoing training program for resident surgeons on the rate and success of laparoscopic surgery.

DESIGN

Retrospective chart review (Canadian Task Force classification II-3).

SETTING

University tertiary medical center.

PATIENTS

One thousand forty-six patients with ectopic pregnancy treated at Jackson Memorial Hospital from January 1, 1995, through December 31, 2004.

INTERVENTION

A formal, ongoing laparoscopic training program was established in 1999.

MEASUREMENTS

The rate of laparoscopy, laparotomy, and conversion for each year was compared with the baseline year of 1995 and between the years before and after the establishment of the training program.

RESULTS

Four hundred sixty-eight laparotomies and 578 laparoscopies were successfully completed. The laparoscopic approach rate has increased from 40.9% in 1995 to 86.3% in 2004. By year 2000 and thereafter, significantly more ectopic surgeries were approached through the laparoscope compared with in 1995 (p<.01). By 2000 and thereafter, significantly less conversions occurred compared with the baseline year of 1995 (4.0% vs 18.5%; p = .01).

CONCLUSION

Laparoscopy became the primary approach for the management of ectopic pregnancy in part because of resident participation in an ongoing laparoscopy training program.

Suspected Ectopic Pregnancy

Women who present with pain and bleeding in the first trimester are at risk for ectopic pregnancy, a life-threatening condition. Conditions that predispose a woman to ectopic pregnancy are damaged fallopian tubes from prior tubal surgery or previous pelvic infection, smoking, and conception using assisted reproduction. Many women without risk factors can develop an ectopic pregnancy. A diagnostic algorithm that includes the use of transvaginal ultrasonography, human chorionic gonadotropin (hCG) concentrations, and, sometimes, uterine curettage can definitively diagnose women at risk in a timely manner. The absence of an intrauterine pregnancy above an established cut point of hCG is consistent with an abnormal pregnancy but does not distinguish a miscarriage from an ectopic pregnancy. When the initial hCG value is low, serial hCG values can be used to determine whether a gestation is potentially viable or spontaneously resolving. The minimal rise in hCG for a viable pregnancy is 53% in 2 days. The minimal decline of a spontaneous abortion is 21-35% in 2 days, depending on the initial level. A rise or fall in serial hCG values that is slower than this is suggestive of an ectopic pregnancy. Women diagnosed with an unruptured ectopic pregnancy are potential candidates for medical management with methotrexate. Intramuscular injection with methotrexate can be used to safely treat an ectopic pregnancy with success rates, tubal patency rates, and future fertility that are similar to those obtained with conservative surgery. Success rates using methotrexate are inversely rated to baseline hCG values and are higher using "multidose" compared with "single-dose" regimens. Surgical treatment may be conservative or definitive and should be attempted in most cases via laparoscopy.

Evaluation of the relationship between endometrial thickness and failure of single-dose methotrexate in ectopic pregnancy

OBJECTIVE

To test the hypothesis that endometrial stripe thicker than 12 mm increases treatment failure of single-dose methotrexate for the management of ectopic pregnancy.

STUDY DESIGN

Seventy-three patients with ectopic pregnancy and measured pretreatment endometrial stripe were divided into two groups based on the endometrial stripe thickness (> 12 mm or < or = 12 mm). All patients were candidates for single-dose methotrexate treatment. Variables analyzed between the two groups were endometrial stripe thickness, initial beta human chorionic gonadotropin level (hCG), size of the ectopic mass, presence of fetal heart tones, previous ectopic pregnancy, and clinical outcomes.

RESULTS

Sixty patients had endometrial stripe thickness < or = 12 mm and 13 patients > 12 mm. The two groups were similar in initial hCG, size of ectopic mass, presence of fetal heart tones and rate of previous ectopic pregnancy. The failure rate was significantly higher in the group with endometrial stripe > 12 mm compared to the group < or = 12 mm (n=7, 53% vs. n=3, 5%, P<0.01). The endometrial stripe was significantly thicker in the group with endometrial stripe thickness > 12 mm compared to the group < or = 12 mm (mean +/- SD, 17.64+/-5.82 mm vs. 7.69+/-2.82 mm, P<0.01).

CONCLUSION

Endometrial stripe thicker than 12 mm increases the risk for treatment failure with single-dose methotrexate.

Risk Factors Associated with the Rupture of Tubal Ectopic Pregnancy

OBJECTIVE

To identify risk factors that may lead to the rupture of ectopic pregnancies.

STUDY DESIGN

A retrospective chart review was performed on patients with ectopic pregnancies at the University of Miami/Jackson Memorial Hospital between 1/1/1995 and 3/1/2002. 738 patients were identified with ectopic pregnancies. Women with tubal rupture were compared to those without rupture. Variables analyzed were demographic data, patient-related risk factors (history of pelvic surgery, bilateral tubal ligation, history of pelvic inflammatory disease, previous ectopic pregnancy, intrauterine device use) and beta-human chorionic gonadotropin (betahCG) measurement.

RESULTS

There were 439 (59%) cases with a ruptured and 299 (41%) cases with an unruptured ectopic pregnancy. Multivariate logistic regression analysis revealed that previous ectopic pregnancy (OR 2.88; 95% CI 1.92, 4.33) and betahCG level >or=5,000 mIU/ml (OR 1.85; 95% CI 1.12, 3.06) were the only significant risk factors for tubal rupture.

CONCLUSION

Patients with betahCG levels >or=5,000 mIU/ml and patients with a history of a previous ectopic pregnancy are significantly more likely to experience a tubal rupture.

Risk factors for conversion to laparotomy during laparoscopic management of an ectopic pregnancy

OBJECTIVE

To identify risk factors for conversion to laparotomy during laparoscopic management of ectopic pregnancy.

METHODS

A retrospective chart review of patients who underwent laparoscopy for treatment of ectopic pregnancy, during a 32-month period (6/1999-2/2002), at the University of Miami Jackson Memorial Hospital. We identified 229 patients; 201 had a successful laparoscopy (non-converted group) and 28 who were converted to laparotomy (converted group). Variables analyzed between the two groups were demographic data, patient-related risk factors available to the surgeon prior to the surgery (previous laparotomy, previous laparoscopy, history of PID, history of endometriosis, diameter of ectopic pregnancy as measured by ultrasound, amount of free fluid on ultrasound, BMI), and surgeons' experience.

RESULTS

Out of the 229 laparoscopies, 28 were converted to laparotomy (12.2%). The rate of conversion was significantly higher for less experienced compared to experienced surgeon (OR = 6.1, 95% CI = 2.35-15.88). Significantly more women had a BMI > 30 kg/m2 in the converted group compared to the non-converted group (42% vs. 14%; OR = 4.28, 95% CI = 1.7-10.75) and the converted group had significantly higher rate of large free fluid reported on ultrasound compared to the non-converted group (21.42% vs. 7.46%; OR = 3.38, 95% CI = 1.04-10.61).

CONCLUSION

Less experienced surgeon, BMI > 30 kg/m2, and large amount of free fluid on ultrasound increase the risk of conversion to laparotomy during laparoscopic management of ectopic pregnancy.

A Rare Drug Reaction to Methotrexate After Treatment for Ectopic Pregnancy

BACKGROUND

Ectopic pregnancies are commonly diagnosed and treated in physicians' offices. In the hemodynamically stable patient, therapy often includes treatment with methotrexate. Well-known adverse effects of this drug include mucositis, abdominal cramping, and malaise. We report a case of a rare drug reaction after treatment with methotrexate.

CASE

A 34-year-old, gravida 2, para 0, at 7 weeks of gestation by last menstrual period was diagnosed with an ectopic pregnancy and treated with methotrexate. The patient had an anaphylactoid reaction shortly after administration of methotrexate.

CONCLUSION

Methotrexate is a commonly used therapy for ectopic pregnancies in the outpatient setting. Practitioners should be aware of the potential adverse reactions to methotrexate.

Adnexal mass with pelvic pain

In a pregnant woman who presents with acute pelvic pain and an adnexal mass, pregnancy-related etiologies, such as ectopic pregnancy or ovarian torsion, are typically the first diagnoses to be considered. Many other causes of pelvic pain associated with an adnexal mass can occur in pregnant patients, however. Some causes are benign and others require urgent management and treatment. Clinical presentation and physical examination can be misleading in pregnancy. The location of pain may be atypical for the pathologic entity, the pain may be muted, and in the case of infection, fever and leukocytosis can be absent. US examination is a safe and effective method for evaluating these patients. Sonographic characterization of adnexal masses may make a definitive diagnosis or focus the differential, which allows for prompt and appropriate treatment of patients.

Menstrual disorders in adolescence

Problems associated with menstruation affect 75% of adolescent females and are a leading reason for visits to physicians. This chapter begins with a review of the timing and characteristics of normal menstruation during adolescence. It then discusses the evaluation and management of adolescents with amenorrhoea, dysmenorrhoea and abnormal uterine bleeding. An approach to adolescent amenorrhoea is presented that utilizes primary versus secondary amenorrhoea, delayed versus normal pubertal development, and the presence or absence of hyperandrogenism as nodal points for decision making. The differential diagnosis of dysmenorrhoea and the management of primary dysmenorrhoea and endometriosis are reviewed. The section on abnormal uterine bleeding contrasts anovulatory dysfunctional uterine bleeding (DUB) with bleeding secondary to problems of pregnancy, uterine pathology, exogenous hormone use and systemic bleeding disorders.

The pharmacology of methotrexate

Ectopic pregnancy (EP) is a major cause of maternal morbidity and mortality. The treatment of this condition is primarily surgical, but medical management in selected cases is safe, effective, cost-effective and eliminates the morbidity of surgery. Methotrexate (MTX) is a folate antagonist that can be used for non-oncologic purposes including the treatment of EP. The dose and duration of MTX therapy for EP is much lower than that used in oncology cases, thus reducing side effects and increasing safety. MTX selectively acts on rapidly dividing cells, such as trophoblast cells which comprise the implantation site of the early gestation. The two most common methods of administering MTX to patients with EP are im. administration of a single-dose, based on body surface area and calculated by the equation 50 mg/m(2) (without the need for leucovorin rescue), or the multiple-dose regimen of 1 mg/kg of MTX, alternating with 0.1 mg/kg of leucovorin rescue. Both methods have a similar side effect profile, resulting in the rare occurrence of nausea, vomiting, stomatitis, elevated liver function tests, anorexia and diarrhoea. The two methods yield success rates similar to those of conservative surgical therapy with similar future fertility. The potential single- and multi-dose methods have never been directly compared, but it appears that the success of multiple dosing is more effective. As the efficacy of MTX therapy is not 100%, women must be followed clinically until there is compete resolution of human Chorionic Gonadotropin (hCG) titres from their serum.